Incidents of self-harm in transgender youths are much higher than for their peers, and the reasons for this are varied and often complex – as this research project set out to explore.
By Joe Pardoe and Dr Gemma Trainor
Research suggests that a far greater proportion of transgendered individuals engage in self-harm compared to those who are cisgendered – those whose self-identity corresponds with their biological sex (Conolly et al, 2016; Jackman et al, 2016). Furthermore, statistically speaking, transgender youths represent one of the most vulnerable groups within our society as regards prevalence of self-harm and non-suicidal self-injurious behaviour, with reported rates among this population escalating annually (Reisner et al, 2015).
Liu & Mustanski (2012) found that 13-45% of transgender individuals between the ages of 16 and 20 engage in self-harm. Despite these alarming statistics, research has found a deficit in suitable therapeutic intervention for this cohort, largely due to clinical guidelines being supported by very limited research evidence (de Vries et al, 2016). Similarly, a literature review for this paper revealed remarkably modest attention from academic, qualitative research on this topic, with the majority of studies aggregating rates of self-injurious behaviour but providing little explorative data into the phenomenon, with scant focus on individual experiences (Lytle et al, 2016).
Young people who identify as transgender can find articulating their emotional distress overwhelming, frequently preferring to ask for help online rather than approaching mental health services (McDermott, 2015). McDermott & Roen (2012) investigated the social context of online forums for transgender youths seeking support for self-harm. They concluded that a paucity in understanding of the emotional life of these young people was largely responsible for the inadequacy of current social care interventions for this population.
In order to garner a variety of insightful perspectives on the topic of self-harm among transgender youth, this study applied thematic analysis to a corpus of data that was gathered from online support forums. The rationale behind applying this research method was that perspectives would have been offered in an environment in which subjects felt comfortable to speak openly, without restriction or moderation.
Online forum members adopted a variety of gender terms to self-identify. For the purposes of this study, the prefix term ‘trans’ will be used to describe the individuals who are the subject of this study; an umbrella term that includes (but is not limited to) those who identify as: transvestite, transsexual, polygender, genderqueer, trans male, trans female, cross-dressing, gender variant, dual-gendered, and non-gender conforming or non-binary (Erickson-Schroth, 2014). The foremost ambition of this study is to bring the increasing prevalence of self-harm in transgender youths to the attention of professionals, with urgency, and to encourage further qualitative exploration into the phenomenon so that appropriate therapeutic interventions and modes of support may be developed in the future.
This study presents various first-hand insights from transgender youths seeking support for self-harm, which were aggregated following a thematic analysis of 40 threads (member/guest created ‘topics’) from 12 online support forums. The forums had been created specifically to provide support to LGBT+, or specifically gender-variant youths, who engage in self-harm or self-injurious behaviour, or to provide information and support for those in a position of care for trans youths.
This study follows the example of McDermott et al (2013), which highlighted the advantages of applying this methodological approach to qualitative research into self-harm in trans youth. Researchers found that the approach is especially advantageous due to three key factors: data is generated that offers diversity in terms of sexuality and gender identities, data is unmediated by researchers and complex psychosocial emotional data is made available to researchers.
Data presented was openly viewable to the general public and did not require membership registration or special permissions to gain access. In order to ensure that the study was ethically sound, and to protect the confidentiality of those who posted on the forums, all names – aliases or otherwise – have been changed, and any identifying details such as addresses have been removed.
Analysis and discussion
Thematic analysis revealed a variety of issues holding relevance to research aims, the breadth and complexity of which extended far beyond the scope of this study to explore definitively. In order to meet this study’s research aims with concision and substance, five distinct themes will be discussed, representing some of the more frequently recurring and resonant subjects raised in forums. This was often, though not always, indicated by the number of replies submitted to a given post. The five themes are: anger at own body, barriers to support, issues with available treatment, self-harm as an addiction or obsession, and relationship issues.
Anger at own body
Self-harm was often described as a means of expressing thoughts of powerlessness. Sasha mentioned how close friends within her support network felt imprisoned by their bodies, which in turn became the target of their frustrations, giving rise to the theme ‘anger at own body’. “I know others who felt (self-harm) gave them control […] they knew they were men and women, but their body stopped them so they abused their body.”
While Sasha spoke about those who express an actively hostile relationship with their bodies, by contrast many others described a feeling of separation, with being confined in the wrong body evoking feelings of depersonalisation. As Jessica reflected: “(Self-harm) was like a way to prove to myself how worthless me & my body was, a way of proving to myself that I was a worthless "thing" rather than a person.”
Self-injurious behaviour was often focused on the genitals or breasts specifically; anatomical markers delineating the gender to which a given subject felt they did not belong. Michael described his method of routinely targeting his genitals, sometimes as an intended preliminary step for attempting self-castration: “I used to constrict blood flow to my privates using rubber bands or string for as long as I could tolerate the pain.”
Replying to Michael, David shared that his own ideas about self-castration began when he was very young: “I remember as a pre-teen (9-12), applying an electric current to my boy parts in hopes of doing the same thing.”
David’s comment illustrates what was true for many subjects; that the elected method of self-harm was part of a long-established routine, often beginning in early adolescence. Steph explained that she had gone through many phases of experimentation when it came to inflicting self-harm, and had also considered self-castration, but had ultimately refrained from taking that particular step with the foreknowledge that it could prevent her from undergoing gender reassignment surgery in the future: “I went so far as to buy certain "torture" toys, and even made a couple […] I now know GCS for either gender, (it) works best on healthy tissue at the time of surgery and not tissue that has been badly scarred or amputated.”
Steph’s comment drew light to how those who are transgendered often face extraneous difficulties transitioning when they also self-harm, giving rise to the next theme, ‘Issues with available treatment’.
Issues with available treatment
In many cases, subjects felt that their self-harm and associated feelings of depression and anxiety were exclusively symptomatic of gender dysphoria. Tina encapsulated this insightfully with her recollection of beginning to transition. Tina explained that: “When I visited a doctor to start testosterone via informed consent, we discussed my issues and both mutually felt that dysphoria was likely the root cause of the majority of my feelings. My anxiety was all related to how people perceived me, being put in situations where I had to be ‘female.’”
The reasons for trans youths receiving a diagnosis, or multiple diagnoses, of various mental illnesses proved a contentious topic of conversation. Individuals like Tony felt his self-harming as a trans person was a feature of his diagnosis: “I'm not saying that cutting/burning/SI for transgender people is necessarily indicative of borderline personality disorder, but I feel it is true for me.”
Many others felt that they had been misdiagnosed, or were being treated for a disorder that would never resolve the underpinning issue; that of being trapped in the wrong body. For example, Charlotte mentioned that when she began making arrangements to undergo gender realignment surgery, her desire to self-harm decreased: “…Self-harm […] slowed down when I decided to open up about wanting to transist, and stopped almost completely when I started taking big strides toward that goal.”
There was little debate around whether available therapeutic measures were always useful to subjects to reduce or subvert the desire to self-harm. In terms of recommended measures that could be taken to avoid continued self-harm, almost every subject disclosed that they had been dissatisfied at some point over the course of their treatment.
Michael, for example, described a popular form of aversion therapy that had been suggested to him, whereby he was advised to snap a rubber band on his wrist when the compulsion to self-harm arose: “Rubber bands didn’t help me at all. It was like being teased with a huge chocolate cake when you’re on a diet. On a couple of really bad days, I actually used the rubber band so much that it split my skin, which negated the whole point of it.”
This is not to say that all therapeutic measures were found to be unhelpful. Of those providing higher rates of success, dialectical behaviour therapy (DBT) was mentioned in a particularly favourable light. Michael spoke about using techniques he had learnt in DBT when his dysphoria had a strong influence over his mood: “I have found these types of techniques to be very effective in staving off depression brought on by a gender dysphoria episode.”
Further, as Tina mentioned earlier, trans youths can be extremely sensitive to the way they are perceived by others, often as a result of being subjected to discrimination, abuse or bullying in the past (McDermott et al, 2008).
Jason described how DBT came in useful for him around issues of paranoia: “[…] the DBT skills that really helped me were the ones about stopping the 'Black and White...All or Nothing’ thinking. And skills to stop projecting; the 'I know what you are thinking/saying about me' stuff.”
As well as problems regarding therapy, subjects frequently mentioned feeling excluded from accessing the support they needed to transist, and that this could influence the desire to self-harm.
Barriers to support
Some guests mentioned electing not to seek professional support because they were anxious about overzealous or inappropriate treatment at the hands of mental health practitioners. Georgie expressed his fears that reaching out for help would lead to his being admitted to a mental hospital: “I dread the prospect of being dragged/drugged off to the psychiatric ward. I'm not up to telling anyone, outside of here, the real nature of my injuries.”
As an aside, Georgie’s comment once again highlighted how indispensable online forums can be for trans individuals as a resource for building a social network and receiving emotional support. The central concern for subjects discussing this topic tended to revolve around whether engaging in self-harm would create a barrier to undergoing surgery due to implications of diminished responsibility. Many felt they were unfairly pressured to prove themselves worthy of receiving treatment; in some cases, individuals explained that their desire to realign their gender was treated as part of a mental illness. Indeed, the Diagnosis and Statistical Manual of Mental Disorders (DSM-5) still contains an entry for ‘gender dysphoria’.
On the other hand, some felt that these precautions were a necessity, and benefitted the patient. Louis said that: “Doctors in general feel better referring you for HRT (Hormone Replacement Therapy) or surgeries when […] any pre-existing conditions are known and managed, you have a solid support system, you are well informed, etc.”
For trans people, the desire to self-harm can arise from feelings of desperation and isolation when the prospect of approaching mental health services for support is too overwhelming. As previously mentioned, this compulsion to self-harm as a way to alleviate the stress of living as a transgender individual can become part of a routine. This gave rise to the theme ‘Self-harm as an addiction or obsession.’
Self-harm as an addiction or obsession
Subjects discussed feeling compelled to self-harm as a means of retreating from the reality of their situation; a similar rationale expressed by drug users living in adversity. Further, subjects also described inflicting self-injury as a 'fix'; a term, among many others, borrowed from the lexicon associated with drug use.
Abstaining from self-harm led forum member David to comment that: “I've been self-harming myself for almost seven years […] I've tried to stop cold turkey.”
Similarly, Lukas expressed his urge to self-harm after experiencing a family crisis: “Last night I had a really bad crash and almost went back to the habit.”
Further expanding on the drug use analogy, Lukas said that others within his social network had come to engage in self-harm more as an indulgence than a coping strategy: “[…] the release of endorphins became addictive and it was a 'rush' they looked forward to […] a chemical rush!”
Those who self-harm often go to considerable lengths to conceal evidence of self-injury (Trainor et al, 2010), especially when self-harming behaviour becomes habitual (Webb, 2002). A reduction or cessation in continued self-harm was often brought about when the issue began to cause problems within a social context.
Of the topics discussed in online forums, many of those inspiring more emotional responses pertained to family relationships, and relationship issues regarding a significant other. Prior study indicates that those who may have self-harmed initially find an outlet for similar pain-seeking impulses by becoming involved in a consensual relationship that encompasses an element of bondage and sadomasochism (BDSM) (Ortmann & Sprott, 2012).
Simon's comment was consistent with this finding: “I found BDSM play. With the right person, it is safe, sane and consensual. It can provide all the pain I need.”
Simon went on to describe his relationship as loving and trusting, and says his partner is accepting of his identity as a transgender male. Inversely, there also were instances of prolonged abuse reported by those who had entered into a relationship that initially encompassed a consenting BDSM element.
Natalie reflected extensively upon her pattern of inflicting self-harm as a cyclical component of being in a relationship with a string of abusive partners, and said that maintaining victimhood at the hands of an abusive partner could constitute a type of self-harm in itself. “I have a long-term emotionally abusive relationship with a friend/partner/enemy. She really pulled a major "I love you/I hate you" scene on me once and I broke down. I cut deeply on my upper arm, about 15 (inches).”
Natalie’s cyclical pattern of abusive partners coupled with self-harm around gender dysphoria was echoed by Paul with regard to his family. Paul described his home situation, whereby a lack of acceptance from his family discouraged him from seeking to begin gender realignment surgery, and in turn led to him inflicting self-harm as a means of escaping the stress of the situation: “I was depressed because I had known for years that I wanted to transition but kept putting it off in hopes that I would outgrow it, or my family would become more accepting.”
Time and again, forum members described how a lack of understanding and unwillingness to accept the need to transit from other family members led to deep feelings of desperation and depression, which contributed significantly to repeated self-harm. David explained that: “Early in my transition, I became emotionally hypersensitive to criticism from a member (of my family) that plunged me into a deep depression: my response was to cut.”
Findings indicate that many trans youths experience severe social exclusion and isolation, including, in many cases, hostile responses from family members. As such, family intervention should be prioritised to promote understanding and education on trans issues in order to reduce the stigmatising of this vulnerable population.
Further, the complexity and breadth of issues that arose throughout this study served to emphasise how gender identity can permeate all aspects of a person's life. Future study may wish to explore the benefits of holistic psychotherapeutic measures, including DMT therapy and family therapy, and how transgender individuals may recognise signs that they are involved in an abusive relationship.
Better promotion for support would also be beneficial; in particular, online forums such as those which provided the data for this study, ought to receive more widespread promotion as an invaluable resource for trans youths seeking support for self-harm and trans issues.
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About the authors
Joe Pardoe is a psychology post-graduate
Dr Gemma Trainor is a lecturer in mental health at Kings College London